Esophagus - Black (Necrotic) Esophagus
Comments: An 89 yo man presented with a history of black, tarry stools for 1 day. His past medical history was notable for atrial fibrillation with rapid ventricular response, hypertension, and a complicated urologic history with large exophytic renal cysts, urethral stricture, abdominal abscess, fungal UTI, and acute renal failure requiring bilateral nephrostomy tubes.
An upper endoscopy revealed severe circumferential ulceration of the entire esophagus beginning at the gastro-esophageal junction. There was also a brown-yellow particulate matter on the esophagus surface which when washed revealed a black-brown appearing esophageal mucosa consistent with “black esophagus.” Post-EGD, he was placed on maximal proton pump inhibitor doses and sucralfate and gradually started a clear liquid diet.
Approximately 2 weeks after upper endoscopy, he began reporting difficulty with swallowing resulting in regurgitation of both liquids and solids.
A repeat upper endoscopy was performed with fluoroscopic assistance which showed a stricture in the mid to distal esophagus from 25cm to 35cm.
The mucosa of the esophagus was ulcerated and friable with regenerative squamous epithelium. Only a 5mm diameter endoscope could be passed through the strictured area. A single clip was deployed through the endoscope to mark the proximal end of the stricture. A zebra wire was passed into the gastric lumen and under fluoroscopy a 12cm metal stent was advanced over the wire, deployed, and confirmed.
Black esophagus or acute esophageal necrosis (AEN) is rare and dramatic when found. Endoscopy is notable for a circumferential black coloration of the esophageal mucosa that stops abruptly at the gastroesophageal junction.
It predominately affects the lower 1/3-2/3 of the esophagus. This is with or without exudate. It correlates with mucosal necrosis on histology. AEN can present as gastrointestinal bleeding. It has an associated high morbidity and mortality. Complications such as death (~30%), stricture (~10%), perforation (<10%), and mediastinitis (<10%) can occur. Risk factors include cardiovascular disease, hemodynamic compromise, gastric outlet obstruction, alcohol abuse, compression, trauma/surgery, malnutrition, infection, and chronic diseases such as diabetes, malignancy, renal insufficiency, and pulmonary disease.
| Contributed by: |
Cynthia Leung, MD GI Fellow Palo Alto Veteran's Hospital Stanford University School of Medicine Roy Soetikno, M.D. Associate Professor of Medicine Palo Alto Veteran's Hospital Stanford University School of Medicine |
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Citation: Leung, C. & Soetikno, R. (Mar 02 2008). Esophagus - Black (Necrotic) Esophagus. The DAVE Project. Retrieved Feb, 8, 2010, from http://daveproject.org/viewfilms.cfm?film_id=714 Times viewed since Feb 2006: 5113 |
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